WELLNESS INCENTIVE (HRA) PLAN DESIGN GUIDE

WELLNESS INCENTIVE (HRA) PLAN DESIGN GUIDE Please fill out this form in its entirety and return to SelectAccount 45 days prior to your effective date in order for us to properly administer your plan. If you have any questions on how to complete the form, please call our Group Leader Line at 1-888-460-4013 or our Agent Service Line at 1-888-460-4015. If you are a 51+ group, please contact your account manager. When complete, either fax form to 651-662-7247 or toll-free at 1-866-231-0214, or mail to SelectAccount, PO Box 64193, Saint Paul, MN 55164. Incomplete forms will result in delays setting up your plan. I. EMPLOYER INFORMATION Employer s Name Employer s Street Address City State Zip Code Employer s Tax I.D. Number (required) Nature of Business Type of l S Corporation* l C Corporation l Partnership* l Sole Proprietor* Corporation l Political Subdivision/Church l LLC* l Other *2% or more shareholders of an S Corporation, along with partners in a partnership, sole proprietors and participants of an LLC or PLLP do not have access to an Wellness Incentive HRA. Number of Employees Eligible for Plan: Person Responsible For Authorization of Plan Design: For Office Use Only: SelectAccount Group Number Enrollment Specialist Market Segment Main Contact Person Title Email Address II. AGENT / BROKER INFORMATION Agent / Broker Name (if applicable) Email Agent / Broker Code Agent / Broker Phone ( ) Agency / Broker Name (if applicable) Email Agency / Broker Code Agency / Broker Phone ( ) III. TRANSFER OF ADMINISTRATION Is SelectAccount taking over administrative services from another Wellness Incentive HRA administrator? l Yes l No (If yes, SelectAccount will contact you.) 1 MII Life, Inc., d.b.a. SelectAccount

IV. WELLNESS INCENTIVE HRA FUNDING OPTION #1 l Wellness Incentive HRA Pays First With this option, you, the employer, fund the Wellness Incentive HRA as expenses are reimbursed up to a predetermined amount. The Wellness Incentive HRA pays until the funds are exhausted. Vendor for health and wellness incentive benefit plan: l Blue Cross Blue Shield of Minnesota l Other: (name) (SelectAccount file format requirements must be used) Incentive Contribution Frequency: l Annually l Periodically throughout plan year Please indicate the contact person(s) for enrollment and incentive contribution information, if different from main contact person: Eligible Expenses Wellness Incentive HRA dollars may be used to reimburse: (Please check all that apply) l Health Plan eligible medical expenses l Health Plan eligible drug expenses l All IRC section 213(d) eligible expenses l COBRA premiums and insurance premiums Reimbursement Level 100% of eligible expenses Rollover Indicate what happens to unused balances at the end of the plan year. l Entire balance rolls over to subsequent plan year l No balance rolls over l A percentage of the balance rolls over to subsequent plan year % l A dollar limit on the amount that can roll over to the subsequent plan year. Rollover amount cannot be the same as funding amount. Indicate limits below: Cap on Wellness Incentive HRA Balance (Not Recommended) Is there a cap on the overall balance (including Rollover) that can accumulate in the account? l Yes l No Please indicate amounts below: 2

IV. WELLNESS INCENTIVE HRA FUNDING OPTION #1 (continued) Runout Period Participants have months after the end of the plan year to submit claims incurred during that plan year. The runout period noted above begins at termination date for terminated employees. Terminations Indicate what happens to the HRA balance when a participant terminates. NOTE: Account balance stays with terminated participant if COBRA has been elected (mandatory.) Please check one of the following options: _l Account balance returns to employer if terminated participant or eligible dependent does not elect COBRA. (default) l Account balance remains with terminated participant or eligible dependent to spend-down until funds are depleted. If spend-down is selected, eligible expenses for terminated participants remain the same as for active participants. Spend-down is subject to any applicable rollover and runout period provisions and fees. (Only available for funding options #1 & #2 - not available for funding option #3.) Crossover Offering crossover eliminates the need for participants to complete and file a claim form to be reimbursed for eligible health plan expenses. The crossover election applies across all spending accounts (i.e. medical FSA, HRA (including a Wellness Incentive HRA), or HSA). Medical Crossover Eligible health plan expenses (i.e. deductible and/or coinsurance) as indicated on the Explanation of Benefits will be electronically transferred to SelectAccount. Claims will be processed and reimbursed according to the participant s available balance. Please note: crossover is not appropriate for any participants who have secondary health coverage with Blue Cross or another carrier. (This feature is only available if health plan is with Blue Cross and Blue Shield of Minnesota, Blue Cross and Blue Shield of Kansas, CCStpa, or BlueLink Tpa.) Along with medical crossover, any available spending account balance(s) are accessed when purchasing a prescription drug at the pharmacy at point of service. This feature is only applicable when Prime Therapeutics is the pharmacy _ benefit manager and prescription drug benefits are allowed with the spending account plan. Select one: l Automatically enroll all participants in medical crossover. (Participants may opt out by completing the medical crossover form F7856.) l Offer medical crossover to participants. (Participants may elect crossover by completing the medical crossover form F7856. Highest participant fee applies. Please refer to the fee schedule.) l Do not offer medical crossover to participants. Highest participant fee applies. Please refer to the fee schedule. Dental Crossover - only available if eligible expenses chosen are all IRC section 213(d). Do you offer dental coverage through Delta Dental of Minnesota? l Yes - complete the dental crossover section below l No - Default Eligible dental plan expenses (i.e. deductible and/or coinsurance) as indicated on the dental Explanation of Benefits, plus other patient responsibility amounts will be electronically transferred from Delta Dental of Minnesota to SelectAccount. They will be processed and reimbursed according to the participant s available balance. Please note dental crossover is not appropriate for any participants who have secondary dental insurance coverage. Electing this feature does not impact the monthly participant fees. Select one: l Automatically enroll all participants in dental crossover. (Participants may opt out of dental crossover by completing the dental crossover form F7854.) l Offer dental crossover to participants. (Participants may elect crossover by completing the dental crossover form F7854.) l Do not offer dental crossover to participants Pay-the-Provider (This feature is only available if health plan is with Blue Cross Blue Shield of Minnesota) This feature allows a participant to have their medical claim reimbursements sent directly to their provider rather than to their home address or directly deposited into their bank account. This is only available for participants who have elected crossover. Additional fee applies to all participants regardless of their pay-the-provider election. Please refer to the fee schedule. Select one: l Automatically enroll all participants in pay-the-provider. Must also select auto-enroll in medical crossover. (Participants may opt out of pay-the-provider by completing form F9089.) l Offer pay-the-provider to participants. (Participants may elect pay-the-provider by completing form F9089.) l Do not offer pay-the-provider to participants. 3

V. WELLNESS INCENTIVE HRA FUNDING OPTION #2 l Employee Pays First Wellness Incentive HRA With this option, the employee pays out of pocket until a preset amount has been paid. When this threshold has been reached, the Wellness Incentive HRA pays until exhausted. You, the employer, fund the Wellness Incentive HRA as expenses are reimbursed up to a predetermined amount. After that the employee pays out of pocket until the health plan deductible is reached. Once the deductible is met, the health plan starts to pay subject to any coinsurance amounts. Additional fee applies to all participants. Please refer to the fee schedule. Health Plan Administrator Health plan carrier Blue Cross Blue Shield of MN Health plan group #(s) Are health plan accumulations calendar year or plan year? l Calendar Year l Plan Year Vendor for health and wellness incentive benefit plan: l Blue Cross Blue Shield of Minnesota l Other: (name) (SelectAccount file format requirements must be used) Incentive Contribution Frequency: l Annually l Periodically throughout plan year year as requirements are met Please indicate the contact person(s) for enrollment and incentive contribution information, if different from main contact person: Requirements Group must have Blue Cross and Blue Shield of Minnesota health plan (currently not available for CCStpa or BlueLink Tpa groups) Wellness Incentive HRA plan year must match the health plan deductible accumulation period (calendar vs. plan year) Automatic enrollment in medical crossover Only eligible expenses are Health Plan eligible Medical and/or Health Plan eligible Drug - all IRC Section 213(d) expenses are not allowed Wellness Incentive HRA claim reimbursement level is 100% Indicate your health plan deductible amounts by coverage tier: Indicate the Employee Responsibility Amount*: (this is the amount that the employee will pay out of pocket prior to reimbursement from the Employer Funding Amount) 4 - Participant + Children =$ 4

V. WELLNESS INCENTIVE HRA FUNDING OPTION #2 (continued) Eligible Expenses Wellness Incentive HRA dollars may be used to reimburse: (Please check all that apply) l Health Plan eligible medical expenses l Health Plan eligible drug expenses Rollover Indicate what happens to unused balances at the end of the plan year. Rollover dollars can only be used AFTER the annual employee pays first pre-set threshold amount has been paid. (Select only one) l Entire balance rolls over to subsequent plan year l No balance rolls over l A percentage of the balance rolls over to subsequent plan year % l A dollar limit on the amount that can roll over to the subsequent plan year. Rollover amount cannot be the same as funding amount. Indicate limits below: Cap on Wellness Incentive HRA Balance Is there a cap on the overall balance (including Rollover) that can accumulate in the account? l Yes l No If yes, the recommended cap is the annual deductible amount or total annual out-of-pocket amount. Please indicate amounts below: Runout Period Participants have months after the end of the plan year to submit claims incurred during that plan year. (The standard runout period is 15 months) Terminations Indicate what happens to the Wellness Incentive HRA balance when a participant terminates: (Please check all that apply) l Account balance stays with terminated participant if COBRA has been elected. l Account balance returns to employer. Medical Crossover Eligible health plan expenses (i.e. deductible and/or coinsurance) as indicated on the Explanation of Benefits will be electronically transferred to SelectAccount. Claims will be processed and reimbursed according to the participant s available balance. All participants are automatically enrolled in this feature. Please note: crossover is not appropriate for participants who have secondary health coverage with Blue Cross or another carrier. Participants may opt out by completing the medical crossover form F7856. The crossover election applies across all spending accounts (i.e. medical FSA). Pay-the-Provider This feature allows a participant to have their medical claim reimbursements sent directly to their provider rather than to their home address or directly deposited into their bank account. This is only available for participants who have elected crossover. Additional fee applies to all participants regardless of their pay-the-provider election. Please refer to the fee schedule. Select one: l Automatically enroll all participants in pay-the-provider. (Participants may opt out of pay-the-provider by completing form F9089.) l Offer pay-the-provider to participants. (Participants may elect pay-the-provider by completing form F9089.) l Do not offer pay-the-provider to participants. 5

VI. STANDARD STACKING RECOMMENDATIONS Does this plan interact with another account administered by SelectAccount? l Yes l No With Option #1 Wellness Incentive HRA Pays First: 1. Health Plan HRA 2. Medical FSA (if participating) 3. Wellness Incentive HRA With Option #2 Employee Pays First Wellness Incentive HRA: 1. Wellness Incentive HRA 2. Medical FSA (if participating) For account stacking other than standard recommendations, please consult your Blue Cross sales representative. VII. CLAIM REIMBURSEMENT PROCESSING You will receive an automated e-mail notification with the claim reimbursement totals. Sign into the Online Group Service Center to view and print your complete invoice detail under Claim Reimbursement Invoices. Automated Clearinghouse Information (completion of this section is mandatory) I hereby authorize SelectAccount to charge our bank account through Automated Clearinghouse for claim reimbursements made to our employees. The following bank account information is provided to SelectAccount for initiation of this procedure. Bank Name: Type of Account: l Checking l Savings Bank Account Number: Bank ABA Number: (The ABA number is the nine-digit number located in the lower left corner of your check or savings deposit slip) VIII. ADMINISTRATIVE FEES You will receive an automated e-mail notification when your detailed billing information is available and another e-mail notification two business days in advance of the scheduled ACH transaction confirming the amount of funds to be transferred. Sign in to the Online Group Service Center to view and print your complete invoice detail under Administrative Fee Invoices. Automated Clearinghouse Information I hereby authorize SelectAccount to charge our bank account through Automated Clearinghouse for Administrative Fees. The following bank account information is provided to SelectAccount for initiation of this procedure. Please select one: l Use same bank account as indicated for claim reimbursements; OR l Use bank account information indicated below: Bank Name Type of Account: l Checking l Savings Bank ABA Number (The ABA number is the nine-digit number located in the lower left corner of your check or savings deposit slip) Bank Account Number (Funds will be drawn from your bank account on or after the 20th of each month.) 6

IX. ADMINISTRATIVE TIPS ONLINE ACCESS: www. selectaccount.com With SelectAccount, your employees have access to a powerful tool for managing their HRA. By registering with selectaccount.com, your employees can: Enroll in direct deposit Create and view a customized statement View recent claims or reimbursement requests Manage their personal profile You can also access forms and enrollment materials at www. selectaccount.com LOCATIONS: Multiple SelectAccount locations are available for 51+ groups only. If you want multiple SelectAccount locations, please complete and attach the Location Addendum (F8928). Locations must be the same across all products administered by SelectAccount. If you wish to have different ACH accounts by location, please complete the Group ACH Authorization Agreement form (F9055). COORDINATING WITH AN HSA: For participants that have an HRA and an HSA, the HRA provides reimbursement for permitted benefits such as vision and dental care benefits until the health plan deductible is met. Once the health plan deductible is met, all Section 213(d) expenses, excluding deductible expenses, are eligible for reimbursement. This affects only those participants who are eligible to contribute to their HSA. Participants who are not eligible to contribute to an HSA will have a full HRA. Please note: If the HSA is not administered by SelectAccount or the health plan is not with Blue Cross and Blue Shield of Minnesota, the group is required to manually notify SelectAccount which employees are contributing to the HSA. Participants are accountable for submitting the Deductible Verification Form (F8978) to SelectAccount to indicate that the deductible has been satisfied prior to receiving reimbursement for 213(d) eligible expenses. COORDINATING WITH AN FSA: If the HRA allows reimbursement for health plan eligible expenses only, the HRA is primary and the FSA is secondary. If the HRA allows all 213(d) expenses to be reimbursed, the FSA is primary and the HRA is secondary because unused FSA funds are forfeited if not used for the applicable plan year. ACCOUNT FEES: For participants who have an HRA stacked with a SelectAccount FSA, only one monthly participant fee will apply. Participant fees are billed monthly via mail and are payable by ACH. You will receive one bill for the entire group including the billed amount for each location (if applicable). X. SIGNATURES It is agreed that necessary information concerning participants or participants and their dependents participating in or subsequent to the effective date of the Plan and participants whose participation is to be changed or discontinued shall be furnished to SelectAccount on a timely basis. I HAVE READ AND UNDERSTAND THE CHOICES WITHIN THIS PLAN DESIGN GUIDE. INFORMATION ON THE PLAN DESIGN GUIDE AND ANY ANCILLARY INFORMATION PROVIDED FOR THE PURPOSE OF ENROLLING IN THIS PLAN ARE, TO THE BEST OF MY KNOWLEDGE, CORRECT AND COMPLETE. Signature Date Printed Name Title 7